I liked your comment about the Naylor report. I used to be the science critic, so I've actually read the 289-page Naylor report. Which parts of that do you think need to be implemented to assist with AMR?

There are several aspects to the Naylor report. Certainly science that is directed for the sake of science is really important. A key emphasis of the Naylor report is that we need to go back and just embrace science, and have investigator-initiated science that is not necessarily goal-oriented. I think that's an important element of it.

We also need to be able to invest in young investigators and mid-career investigators. One of the things that the Naylor report pointed out is how we have this funnelling of researchers and it's very thin for young and mid-career investigators.

Very few trainees want to get into the field of AMR because there are no dollars in it. If I were to choose an area of science that I wanted to publish on, I could choose AMR, where I might have three or four journals to publish in and there may be one granting agency in the country where I can get dollars, or I could choose cancer or heart disease where I may have 10 granting agencies and maybe 100 different journals that I could publish in.

That investment to foster research and trainees in the area, from the basics of science to the more complex aspects that involve social sciences, data sciences, and clinical sciences, I think is really important.

If I can add one quick thing, I thought a really important part of the Naylor report was about fostering innovation in general, because I think we have a pretty stagnant health care system and we don't innovate very easily in our health care delivery.

I think that would infuse creativity, again from the workforce, which I think we need to harness.

The best estimates come from a U.S. think tank, that the average cost for bringing a drug to market is about $2 billion for one drug.

When you ask me the price tag of tackling AMR with the pillars that we've been discussing, I gave it substantially less than that. We need drug solutions. We absolutely need new drugs, but if you look at where you're going to get the best bang for your buck, it ain't gonna be in drug solutions.

My questions are more of a clinical nature. Those who have been here before know that I was a practising emergency doctor for about 20 years.

There are certain things that I saw in my practice. Certainly when I was trained, we were taught that with an infection to use the most basic one that would work, because you don't want to be fostering resistance to the more advanced antibiotics. However, we would notice very glossy ads in medical journals for more advanced antibiotics, and then you'd start seeing people showing up on these.

When Amoxil was still first line for otitis media or ear infection in a child, we were occasionally seeing kids coming into emergency who had been put on Ceclor, which I guess would be the equivalent of using a baseball bat when all they needed was a toothpick.

Have you found any undue influence of advertising to physicians in their antibiotic choices?

I don't think it's as big an issue as it was years ago, because there's no pipeline and no new antibiotics that are making a profit for a pharmaceutical company. The investment in development of new antimicrobials has dropped.

Dr. Levinson, you talked briefly about how some physicians would say they didn't want to get yelled at by the patient, or they were worried about getting sued—that sort of thing. I remember some family doctors I talked to when I was a medical student who would say that if they didn't give it to them, the parent would take their kid to another doctor, and then they would complain that they saw two doctors.

In regard to the medical legal situation, in talking to my American colleagues, I know theirs is a much different medical legal environment. Americans are much more likely to sue their doctors than Canadians are.

Have there been any trends—and, again, I know it may be hard to compare because they've been collecting the data better in the States—in American versus Canadian practices? Has the medical legal environment changed?

It's interesting. I'll handle that, because I've done some research personally on the relationship of communication to medical malpractice. I studied the attitudes of U.S. physicians versus those of Canadian physicians, and Canadian physicians grossly overestimate their risk of being sued. It's such a bad thing for a doctor that we all think it's very likely to happen when it's really.... They still operate as though it's a big driving force, even though it's actually pretty rare in Canada compared to the situation for American physicians.

We've talked a lot to the CMPA, the Canadian Medical Protective Association, about trying to work with physicians to stop doing things. They worry they'll be sued more if they don't do these things, such as prescribing when patients want them to. The CMPA actually thinks that is very unlikely, especially if we work through a consensus among doctors about what good practice means.

I'd like to add some data on that. I happen to have in front of me a communication from the CMPA. This is a year old now, but in the past five years, there were only 150 cases in all of Canada that the CMPA received in which antibiotic use was ever discussed, and essentially none of them were related to underuse. If anything, they were related to antibiotic-related harm.

This would be a fundamental systematic change but if there were standards in prescription writing such that in addition to what you're prescribing you would prescribe the indication for it, then this could be double-checked by the pharmacist. If the pharmacist received this “indication: ear infection” and again it was Ceclor, then the pharmacist could double-check it and call the doctor and ask, “Are you sure you want to do this?” I had a hospital-based practice, and in hospitals this would happen all the time. It was a teaching hospital so there were in-hospital pharmacists who would do that quite regularly. They would ask, “Are you sure this is the right drug? We've noticed a local resistance pattern and we think that this is better.” Would it be helpful if we were to have a prescription monitoring program or prescription writing program for the outpatient setting?

There are a lot of studies looking at how to change physician behaviour. Earlier I mentioned audit and feedback, to tell you how you perform compared to your neighbour. Another one is asking physicians to check off why they're prescribing that particular drug and what the indication is. That has been used quite successfully in a variety of situations to drop ordering, because as soon as you have to say why and what the indications are, you tend to be a bit more judicious. It is one strategy, but there are a host of strategies. This again is about how we can motivate change.

I have to tell you, though, I thought I was confused when you started. It's kind of like one of those roller coaster rides when you think you've got it, and then all of a sudden you'll say something else. That's been fortified by what Dr. Eyolfson has said as well. The situation we're in today is that.... Let's just say that when we talk about educating the public, does this complicate the doctor-patient relationship? Let's face it. Most people now go in to see the doctor and they've looked on the Internet and they have it all figured out. Correct me if I'm wrong, but it appears to me that this confuses even doctors, this whole issue of antibiotics. Am I right?

I think you are. It is a complex issue, which is born from a very young age, because all physicians were children at one point. All of us have a love affair with antibiotics. We love antibiotics. We're told as children that if we don't finish them, we're going to get sick and that no matter how bad they taste, we better take them. You get this emotional attachment and we're all in love with antibiotics. Everything all of us have been talking about goes against our emotional instincts around antibiotics. Then when you try to pair that with the education that most of us had earlier on in our training, which thankfully is starting to change, but it's only just starting to change, it makes it very difficult.

The problem with AMR is that as time has gone on, this problem has grown dramatically. As I said, when I trained, you only needed to know one kind of drug-resistant problem. Now there are a whole bunch of them. They're complicated. They don't really make sense. They have acronyms that aren't relevant to the prescriber. It's very difficult to communicate, and there are no reliable guidelines or centralized information that's easy to digest.